Test Bank for Clinical Nursing Skills:
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,TestmBankmformClinicalmNursingmSkills:mAmConcept-BasedmApproachm4thmEditionmPearsonm
,ClinicalmNursingmSkills:mAmConcept-
BasedmApproach,m4em(Pearson)mEducationmTestmBankmChapterm1:mAssessment
1) Amclientmonmthemmedical/surgicalmunitmcomplainsmofmsuddenmchestmpains.mWhichmactionm
willmthemnursemimplementmfirst?
A) Callmthemhealthcaremprovider.
B) Administermpainmmedication.
C) Reassessmamnewmsetmofmvitalmsigns.
D) Turnmclientmfrommsupinemtomlater
al.mANSWER:m C
Explanation:mA)mThemnursemwillmneedmtomreassessmthemclientmfirst,mbeforemcallingmthemheal
thcaremprovider.
B) Themnursemwillmneedmtomreassessmthemclientmfirst,mbeforemadministeringmpainmmedication.
C) Themnursemneedsmtomimplementmamnewmsetmofmvitalmsignsmfirstmwhenmtheremismamc
hangeminmcondition.
D) Themnursemwillmneedmtomreassessmthemclientmfirst,mbeforemmovingmthemclient,mtomavoidmma
kingmthemchangeminmclient'smconditionmworse.
PagemRef:m2
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:mNursingmProcess:mAssessmentm|mLearningmOutcome:m1.1m|mQSENmCompetenc
ies:mPatient-CenteredmCare
AACNmDomainsmandmComps.:mDomainm2:mPerson-
CenteredmCaremNLNmCompetencies:m RelationshipmCenteredmCare
2) ThemnursemismobservingmthemUAPmtakingmthemtemperaturemofmanmunconsciousmclient.mWhic
hmroutemwillmthemnursemquestionmthemUAPmusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanicm
ANSWER:m A
Explanation:mA)mThemtemperaturemofmanmunconsciousmclientmismnevermtakenmbymmouth.mThemr
ectal,mtympanic,mormscannermmethodmismpreferred.
B) Themrectal,mtympanic,mormscannermmethodmismpreferred.
C) Themrectal,mtympanic,mormscannermmethodmismpreferred.
D) Themrectal,mtympanic,mormscannermmethodmismprefe
rred.mPagemRef:m24
CognitivemLevel:m Applying
ClientmNeed/Sub:mmm SafemandmEffectivemCaremEnvironment:mSafetymandmInfectionmControlmSta
ndards:m NursingmProcess:mEvaluationm|mLearningmOutcome:m1.1m|mQSENmCompetencies:mSafet
ymAACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafety
NLNmCompetencies:m Qualitym&mSafety
1
, 3) Themnursemismchangingmam2-month-
oldmclient'smdiapermandmnotesmthemclientmfeelsmwarmmtomtouch.mWhichmmethodmshouldmthemn
ursemusemtomcheckmthembaby'smtemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicmmembran
emANSWER:m C
Explanation:m A)mOralmismusedmformagem3mormolder.
B) Themrectalmroutemismthemleastmdesirable.
C) Themaxillarymroutemmaymnotmbemasmaccuratemasmothermroutesmformdetectingmfeversminmchildren.
D) Themtympanicmmembranemmaymbemusedmform3mmonthsmorm
older.mPagemRef:m29
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:m NursingmProcess:mEvaluatingm|mLearningmOutcome:m1.2m|mQSENmCompetencies:mSa
fetymAACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafety
NLNmCompetencies:m Qualitym&mSafety
4) Amclientmcomesminmwithmexacerbationmofmchronicmobstructivempulmonarymdiseasem(COPD).m
Whichmnoninvasivemdiagnosticmtestmwillmthemnursemimplementmtomknowmthatmthemclientmismrecei
vingmenoughmoxygen?
A) Chestmx-ray
B) Pulsemoximeter
C) Arterialmbloodmgasses
D) Assessmentmofmrespiratorymra
temANSWER:m B
Explanation:m A)mAmchestmx-raymismnotmanminterventionmamnursemcompletes.
B) Ampulsemoximetermprovidesmamnoninvasivemmethodmofmmeasuringmoxygenation,mormoxyg
enmsaturation,minmthembloodmandmprovidesmampulsemreading,mwhichmismespeciallymhelpfulmfor
mthemclientmwithmamrespiratorymillnessmormdisease.
C) Arterialmbloodmgasesmaremanminvasivemdiagnosticmtest.
D) Assessingmamrespiratorymratemismimportantmformthemnursemtomimplement;mhowever,mit
mismnotmamdiagnosticmtest.
PagemRef:m21
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:mNursingmProcess:mImplementationm|mLearningmOutcome:m1.3m|mQSENmCompetenci
es:mInformatics
AACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafetymNL
NmCompetencies:m Qualitym&mSafety
2
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,TestmBankmformClinicalmNursingmSkills:mAmConcept-BasedmApproachm4thmEditionmPearsonm
,ClinicalmNursingmSkills:mAmConcept-
BasedmApproach,m4em(Pearson)mEducationmTestmBankmChapterm1:mAssessment
1) Amclientmonmthemmedical/surgicalmunitmcomplainsmofmsuddenmchestmpains.mWhichmactionm
willmthemnursemimplementmfirst?
A) Callmthemhealthcaremprovider.
B) Administermpainmmedication.
C) Reassessmamnewmsetmofmvitalmsigns.
D) Turnmclientmfrommsupinemtomlater
al.mANSWER:m C
Explanation:mA)mThemnursemwillmneedmtomreassessmthemclientmfirst,mbeforemcallingmthemheal
thcaremprovider.
B) Themnursemwillmneedmtomreassessmthemclientmfirst,mbeforemadministeringmpainmmedication.
C) Themnursemneedsmtomimplementmamnewmsetmofmvitalmsignsmfirstmwhenmtheremismamc
hangeminmcondition.
D) Themnursemwillmneedmtomreassessmthemclientmfirst,mbeforemmovingmthemclient,mtomavoidmma
kingmthemchangeminmclient'smconditionmworse.
PagemRef:m2
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:mNursingmProcess:mAssessmentm|mLearningmOutcome:m1.1m|mQSENmCompetenc
ies:mPatient-CenteredmCare
AACNmDomainsmandmComps.:mDomainm2:mPerson-
CenteredmCaremNLNmCompetencies:m RelationshipmCenteredmCare
2) ThemnursemismobservingmthemUAPmtakingmthemtemperaturemofmanmunconsciousmclient.mWhic
hmroutemwillmthemnursemquestionmthemUAPmusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanicm
ANSWER:m A
Explanation:mA)mThemtemperaturemofmanmunconsciousmclientmismnevermtakenmbymmouth.mThemr
ectal,mtympanic,mormscannermmethodmismpreferred.
B) Themrectal,mtympanic,mormscannermmethodmismpreferred.
C) Themrectal,mtympanic,mormscannermmethodmismpreferred.
D) Themrectal,mtympanic,mormscannermmethodmismprefe
rred.mPagemRef:m24
CognitivemLevel:m Applying
ClientmNeed/Sub:mmm SafemandmEffectivemCaremEnvironment:mSafetymandmInfectionmControlmSta
ndards:m NursingmProcess:mEvaluationm|mLearningmOutcome:m1.1m|mQSENmCompetencies:mSafet
ymAACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafety
NLNmCompetencies:m Qualitym&mSafety
1
, 3) Themnursemismchangingmam2-month-
oldmclient'smdiapermandmnotesmthemclientmfeelsmwarmmtomtouch.mWhichmmethodmshouldmthemn
ursemusemtomcheckmthembaby'smtemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicmmembran
emANSWER:m C
Explanation:m A)mOralmismusedmformagem3mormolder.
B) Themrectalmroutemismthemleastmdesirable.
C) Themaxillarymroutemmaymnotmbemasmaccuratemasmothermroutesmformdetectingmfeversminmchildren.
D) Themtympanicmmembranemmaymbemusedmform3mmonthsmorm
older.mPagemRef:m29
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:m NursingmProcess:mEvaluatingm|mLearningmOutcome:m1.2m|mQSENmCompetencies:mSa
fetymAACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafety
NLNmCompetencies:m Qualitym&mSafety
4) Amclientmcomesminmwithmexacerbationmofmchronicmobstructivempulmonarymdiseasem(COPD).m
Whichmnoninvasivemdiagnosticmtestmwillmthemnursemimplementmtomknowmthatmthemclientmismrecei
vingmenoughmoxygen?
A) Chestmx-ray
B) Pulsemoximeter
C) Arterialmbloodmgasses
D) Assessmentmofmrespiratorymra
temANSWER:m B
Explanation:m A)mAmchestmx-raymismnotmanminterventionmamnursemcompletes.
B) Ampulsemoximetermprovidesmamnoninvasivemmethodmofmmeasuringmoxygenation,mormoxyg
enmsaturation,minmthembloodmandmprovidesmampulsemreading,mwhichmismespeciallymhelpfulmfor
mthemclientmwithmamrespiratorymillnessmormdisease.
C) Arterialmbloodmgasesmaremanminvasivemdiagnosticmtest.
D) Assessingmamrespiratorymratemismimportantmformthemnursemtomimplement;mhowever,mit
mismnotmamdiagnosticmtest.
PagemRef:m21
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:mNursingmProcess:mImplementationm|mLearningmOutcome:m1.3m|mQSENmCompetenci
es:mInformatics
AACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafetymNL
NmCompetencies:m Qualitym&mSafety
2
